Missed IV Antibiotic Doses and Lack of Timely Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors, specifically missed doses of IV antibiotics for two residents with serious infections. For one resident with acute osteomyelitis, multiple stage 3 and 4 pressure ulcers, hemiplegia, and severe protein-calorie malnutrition, physician orders were in place for IV ceftriaxone once daily for two weeks and IV vancomycin for osteomyelitis. Review of the MARs showed that ceftriaxone and vancomycin were not administered on specified dates, with MAR codes indicating "other" and "hold" and references to nurse’s notes. Documentation showed that on one date the PICC line had not yet been placed and that the facility was awaiting vancomycin from the pharmacy, and on another date ceftriaxone was not available. The resident’s record did not contain evidence that the physician was notified of the missed antibiotic doses. For the second resident, who had sepsis from a soft tissue infection, right calf cellulitis and abscess, type 2 diabetes, a history of MRSA infection, and chronic lower extremity wounds, the care plan identified IV antibiotics for sepsis and cellulitis and the risk of infection related to IV/PICC use. A physician order directed IV cefazolin three times daily for infection. The MAR indicated that the order was started the day after admission, but the scheduled morning and afternoon doses were not administered. A health note later documented that the resident had missed antibiotics due to pharmacy issues. Emergency Department documentation recorded that the resident had missed three doses of IV antibiotics, and the resident expressed concern about going without antibiotics and chose to go to the ED for evaluation. Interviews with staff confirmed that delays in medication administration occurred due to pharmacy delivery and PICC line placement issues. An LPN stated that residents miss doses when medications are not delivered timely from the out-of-state pharmacy, which typically delivers nightly and can send stat medications taking approximately two hours if requested. The DON stated that medications should be administered as ordered, that non-initialed or coded MAR entries are considered not administered, and that IV medications should be started right away if available, with physician notification and documentation if there is a delay. The DON also indicated that the process is to notify the provider if a medication has not arrived so the provider can hold or change the order, but in the case of the second resident, the provider was not contacted until after multiple doses had already been missed, and the record did not show when or if the physician was notified of the missed doses. These actions and inactions resulted in multiple missed doses of ordered IV antibiotics for both residents without documented, timely physician notification.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.